放射治疗中基于DICOM-RT模型的电子病历信息系统

电子病历(EMR)是医疗机构对门诊、住院患者(或保健对象)临床诊疗、指导干预的数字化医疗服务工作记录,是居民个人在医疗机构历次就诊过程中产生和被记录的完整、详细的临床信息资源。放射治疗EMR中包含文字、图像等信息,因此,比一般的EMR更加复杂。本文提出一种基于DICOM-RT标准的EMR信息系统,通过使用DICOM-RT的七个对象来实现放射治疗中不同系统、设备间的信息交换和共享,方便放射治疗患者治疗数据的管理,提高放射治疗的效率。     

信息化医院心电信息系统在心电图危急值诊断中的应用

目的评价基于医院信息化平台的心电信息系统在心电图(ECG)危急值诊断中应用及效果。方法构建心电信息系统,与电子病历系统(EMR)及医院信息管理系统(HIS)连接,将门诊、急诊、病房采集的ECG网络传输、共享及储存,设置危急值弹框提醒,利用心电信息系统平台诊断处理危急值。比较心电信息系统应用前后ECG危急值检查及时率、危急值诊断及时率、危急值诊断准确率和医生满意度。结果心电信息系统应用后,ECG危急值检查及时率、危急值诊断及时率、危急值诊断准确率高于应用前(100.00%vs 61.94%,100.00%vs 90.51%,97.63%vs 92.05%),差异有显著统计学意义(P 0.01)。心电信息系统应用后,临床医生和ECG医生对ECG危急值检查及时性、诊断及时性和诊断准确性的非常满意度高于应用前(55.3%vs 0.0%,57.9%vs 13.2%,34.2%vs 7.9%)(P 0.01);检查及时性比较满意度也高于应用前(44.7%vs 13.2%),差异有显著统计学意义;而诊断及时性和诊断准确性比较满意度、基本满意度降低。结论应用心电信息系统有助于ECG危急值诊断,值得各级医院推广应用。     

电子病历发展障碍的分析与对策

随着计算机及信息技术的迅猛发展,全国新的医疗卫生改革以及开展建设医院信息化也相随而来,医院信息系统开始全面升级,电子病历(EMR)逐步闯入了人们关注的焦点,并被公认为医疗信息化发展的方向.通过EMR的共享跨入远程医疗、区域卫生信息化的新时代.本文简要从实施电子病历的标准、医院IT人才、EMR发展的法律地位等方面逐一讨论限制EMR发展的因素,并尝试给出一些解决方案.旨在了解电子病历发展的环境,反映国内卫生信息标准推广的迫切状况及推广的障碍,为管理层决策提供依据.     

内镜黏膜下剥离术/内镜黏膜切除术标本常规制片专家共识

内镜黏膜下剥离术(endoscopic submucosal dissection, ESD)/内镜黏膜切除术(endoscopic mucosal resection, EMR)作为内镜下治疗消化道早期癌的微创手术, 其技术日趋发展成熟, 多项国际指南和共识均推荐ESD/EMR作为消化道早期癌及其前驱病变的首选治疗方式, ESD/EMR标本的诊断结果影响后续治疗方式的选择, 因此ESD/EMR的病理学评估相对于传统外科手术标本应更为严格及精准。在取材制片的过程中存在诸多因素影响ESD/EMR标本病理诊断的准确性。本共识规范了ESD/EMR标本处理以及常规制片的方法, 旨在提高病理诊断的准确性, 为临床进一步诊疗提供可靠、合理的病理依据。     

敬告作者

本刊编辑部自2011年6月起不再向论著类作者提供纸质单行本,如有需要者可向本刊索取文稿的电子版数据(PDF格式),或登录本刊网站(http://www.cjcep.com)自行下载。     

敬告作者

本刊编辑部自2011年6月起不再向论著类作者提供纸质单行本,如有需要者可向本刊索取文稿的电子版数据(PDF格式),或登录本刊网站(http://www.cjcep.com)自行下载。     

敬告作者

本刊编辑部自2011年6月起不再向论著类作者提供纸质单行本,如有需要者可向本刊索取文稿的电子版数据(PDF格式),或登录本刊网站(http://www.cjcep.com)自行下载。     

敬告作者

本刊编辑部自2011年6月起不再向论著类作者提供纸质单行本,如有需要者可向本刊索取文稿的电子版数据(PDF格式),或登录本刊网站(http://www.cjcep.com)自行下载。     

简讯

敬告作者本刊编辑部自2011年6月起不再向论著类作者提供纸质单行本,如有需要者可向本刊索取文稿的电子版数据(PDF格式),或登录本刊网站(http://www.cjcep.com)自行下载。     

国家药监局发布接受药品境外临床试验数据的技术指导原则

正为贯彻落实中共中央办公厅、国务院办公厅《关于深化审评审批制度改革鼓励药品医疗器械创新的意见》(厅字[2017]42号),加强对接受药品境外临床试验数据工作的指导和规范,国家药品监督管理局组织制定了《接受药品境外临床试验数据的技术指导原则》。详情请登录国家药品监督管理局网站http://cnda.cfda.gov.cn/WS04/CL2050/325800.html查阅。     

Electronic medical record systems at academic health centers: advantages and implementation issues.

The growth of managed care has fueled expectations for a more coordinated delivery of clinical services and a reduction of unnecessary utilization. Among the most important issues that constrain these expectations is the transfer of medical information. Electronic medical record (EMR) systems appear to offer substantive advantages over paper records for both containing costs and improving the quality of care. However, incorporation of EMR systems into practice settings has languished. Among the barriers to implementation are software problems of codification and entry of data, security issues, a dearth of integrated delivery systems, reluctant providers, and prohibitive costs. The training programs of academic health centers (AHCs) are optimal environments for testing and implementing EMR systems. AHCs have the expertise to resolve remaining software issues, the components necessary for integrated delivery, a culture for innovation in clinical practice, and a generation of future providers that can be acclimated to the requisites for computerized records. The authors critically review these and other issues of implementing EMR systems at AHCs and propose four necessary steps for financing their implementation.     

Implementation and expansion of an electronic medical record for HIV care and treatment in Haiti: an assessment of system use and the impact of large-scale disruptions

PurposeSystem use is a key criterion of success in an electronic medical record (EMR) implementation, and there is little research on long-term use of systems following implementation. The aim of the paper was to describe the development, implementation and use of iSanté, Haiti's national HIV care and treatment EMR.MethodsTo build a picture of the history of iSanté, we interviewed 11 staff involved with the development and implementation of the EMR, and reviewed organization records. Data entry and report use were ascertained by querying the central patient database.ResultsBy the end of 2010 there were 67 sites with iSanté installed, and the scope of the system had been expanded to include primary care and obstetrics and gynecology. New functionality includes data forms specific to subpopulations, the ability to transfer patient records among clinics, and integration with an electronic laboratory system.We observed fluctuations in use over time, with substantial reductions in the number of active sites during times of large-scale disruptions in Haiti. A surge in report use following the January 2010 earthquake suggests that clinics found the EMR to be a valuable source of data during the recovery phase.ConclusionThere is real potential for EMRs in developing countries to improve clinical practice and make data available for efficient reporting, quality improvement and other population health uses. An approach of continuous system improvement, combined with regular assessments of use, is necessary for achieving an effective, national implementation of a standardized EMR. We have achieved successes in terms of rolling out new functionality and expanding to new sites, but more work remains to be done to improve perceptions of data quality and increase use of population data for accurate and timely reporting.     

Variation in health care--the roles of the electronic medical record

Variation in the use of clinical resources, outcomes, costs, access to health care and quality is a well recognized, ever present feature of health care. It is a phenomenon that affects all sectors of the health care delivery process and is important to clinicians, administrators and patients. As a phenomenon variation can be appropriate or inappropriate and the elimination of inappropriate variation is a fundamental principal behind continuous quality improvement in health care. The primary tools for the management of variation exists within the electronic medical record (EMR). The EMR utilizes the existing and evolving information storage technologies (data repositories) and information management tools (applications), to integrate the elements within this long-term data storage. Through this integration the EMR systems are able to provide knowledge representation in differing formats to the decision-makers and this will facilitate more accurate and appropriate decision-making with subsequent improvements in health care delivery.     

Use of an electronic medical record to profile the continuity clinic experiences of primary care residents.

PURPOSE: To assess the variation in outpatient educational experiences among residents in a primary care internal medicine residency program. METHOD: The authors conducted an observational study within a primary care residency program in Boston, Massachusetts, involving eight primary care residents in 2001-02. A data management system was created that uses information on clinical experiences collected from an electronic medical record (EMR). The EMR records clinical information from patient encounters in resident continuity clinics, including patient demographics and diagnostic codes entered by the residents. Primary and secondary diagnosis from the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) were assigned to clinical categories (e.g., cardiology, orthopedics) and these assignments were programmed into a spreadsheet that could take the diagnostic data directly from the EMR downloads and produce reports using only the primary diagnosis, using all diagnoses, or using the assigned clinical categories. RESULTS: The EMR download showed 2,468 patient encounters for the eight residents in the primary care program. The most common clinical encounters were for health maintenance (17%), cardiology (14%), and women's health (10%). In contrast, rheumatology (0.5%) and hematology/oncology (2%) encounters were less frequent. There were substantial variations among residents in terms of distribution of encounter diagnoses, and the age and gender of patients seen in continuity clinic. CONCLUSIONS: Abstracting data from an EMR represents a feasible method for assessing programmatic and individual learner experiences in the outpatient setting. Such information may help target curricular adjustments to ensure an appropriate diversity and depth of clinical training.     

Caring for individual patients and beyond: enhancing care through secondary use of data in a general practice setting

It is argued that with the introduction of electronic medical record (EMR) systems into the primary care sector, data collected can be used for secondary purposes which extend beyond individual patient care (e.g., for chronic disease management, prevention and clinical performance evaluation). However, EMR systems are primarily designed to support clinical tasks, and data entry practices of clinicians focus on the treatment of individual patients. Hence data collected through EMRs is not always useful in meeting these ends.PurposeIn this paper we follow a community health centre (CHC), and document the changes in work practices of the personnel that were necessary in order to make EMR data useful for secondary purposes.MethodsThis project followed an action research approach, in which ethnographic data were collected mainly by participant observations, by a researcher who also acted as an IT support person for the clinic's secondary usage of EMR data. Additionally, interviews were carried out with the clinical and administrative personnel of the CHC.ResultsThe case study demonstrates that meaningful use of secondary data occurs only after a long process, aimed at creating the pre-conditions for meaningful use of secondary data, has taken place.PreconditionsSpecific areas of focus have to be chosen for secondary data use, and initiatives have to be continuously evaluated and adapted to the workflow through a team approach. Collaboration between IT support and physicians is necessary to tailor the software to allow for the collection of clinically relevant data. Data entry procedures may have to be changed to encourage the usage of an agreed-upon coding scheme, required for meaningful use of secondary data. And finally resources in terms of additional personnel or dedicated time are necessary to keep up with data collection and other tasks required as a pre-condition to secondary use of data, communication of the results to the clinic, and eventual re-evaluation.ConsequencesChanges in the work practices observed in this case which were required to support secondary data use from the EMR included completion of additional tasks by clinical and administrative personnel related to the organization of follow-up tasks. Among physicians increased awareness of specific initiatives and guideline compliance in terms of chronic disease management and prevention was noticed. Finally, the clinic was able to evaluate their own practice and present the results to varied stakeholders.ConclusionsThe case describes the secondary usage of data by a clinic aimed at improving management of the clinic's patients. It illustrates that creating the pre-conditions for secondary use of data from EMRs is a complex process which can be seen as a shift in paradigms from a focus on individual patient care to chronic disease management and performance measurement. More research is needed about how to best support clinics in the process of change management necessitated by emerging clinical management goals.     

An assessment of data quality in a multi-site electronic medical record system in Haiti

ObjectivesStrong data quality (DQ) is a precursor to strong data use. In resource limited settings, routine DQ assessment (DQA) within electronic medical record (EMR) systems can be resource-intensive using manual methods such as audit and chart review; automated queries offer an efficient alternative. This DQA focused on Haiti’s national EMR – iSanté – and included longitudinal data for over 100,000 persons living with HIV (PLHIV) enrolled in HIV care and treatment services at 95 health care facilities (HCF).MethodsThis mixed-methods evaluation used a qualitative Delphi process to identify DQ priorities among local stakeholders, followed by a quantitative DQA on these priority areas. The quantitative DQA examined 13 indicators of completeness, accuracy, and timeliness of retrospective data collected from 2005 to 2013. We described levels of DQ for each indicator over time, and examined the consistency of within-HCF performance and associations between DQ and HCF and EMR system characteristics.ResultsOver all iSanté data, age was incomplete in <1% of cases, while height, pregnancy status, TB status, and ART eligibility were more incomplete (approximately 20–40%). Suspicious data flags were present for <3% of cases of male sex, ART dispenses, CD4 values, and visit dates, but for 26% of cases of age. Discontinuation forms were available for about half of all patients without visits for 180 or more days, and >60% of encounter forms were entered late. For most indicators, DQ tended to improve over time. DQ was highly variable across HCF, and within HCFs DQ was variable across indicators. In adjusted analyses, HCF and system factors with generally favorable and statistically significant associations with DQ were University hospital category, private sector governance, presence of local iSante server, greater HCF experience with the EMR, greater maturity of the EMR itself, and having more system users but fewer new users. In qualitative feedback, local stakeholders emphasized lack of stable power supply as a key challenge to data quality and use of the iSanté EMR.ConclusionsVariable performance on key DQ indicators across HCF suggests that excellent DQ is achievable in Haiti, but further effort is needed to systematize and routinize DQ approaches within HCFs. A dynamic, interactive “DQ dashboard” within iSanté could bring transparency and motivate improvement. While the results of the study are specific to Haiti’s iSanté data system, the study’s methods and thematic lessons learned holdgeneralized relevance for other large-scale EMR systems in resource-limited countries.     

An electronic medical record system for ambulatory care of HIV-infected patients in Kenya

Administering and monitoring therapy is crucial to the battle against HIV/AIDS in sub-Saharan Africa. Electronic medical records (EMRs) can aid in documenting care, monitoring drug adherence and response to therapy, and providing data for quality improvement and research. Faculty at Moi University in Kenya and Indiana and University in the USA opened adult and pediatric HIV clinics in a national referral hospital, a district hospital, and six rural health centers in western Kenya using a newly developed EMR to support comprehensive outpatient HIV/AIDS care. Demographic, clinical, and HIV risk data, diagnostic test results, and treatment information are recorded on paper encounter forms and hand-entered into a central database that prints summary flowsheets and reminders for appropriate testing and treatment. There are separate modules for monitoring the Antenatal Clinic and Pharmacy. The EMR was designed with input from clinicians who understand the local community and constraints of providing care in resource poor settings. To date, the EMR contains more than 30,000 visit records for more than 4000 patients, almost half taking antiretroviral drugs. We describe the development and structure of this EMR and plans for future development that include wireless connections, tablet computers, and migration to a Web-based platform.     

Applying methodology to electronic medical record selection

BACKGROUND: Given the potential for electronic medical records (EMRs) to influence every aspect of health care, there has been surprisingly little rigorous research applied to this emerging health technology. An initial phase of the COMPETE (computerization of medical practices for the enhancement of therapeutic efficacy) program, which investigates the impact of EMRs and electronic decision support on efficiency, quality of care and privacy concerns, developed and used a rigorous approach to EMR selection. METHODS: A multidisciplinary team with clinical, technical and research expertise led an eight-stage evaluation process with direct input from potential clinical users at each stage. An iterative sequence of review of EMR specifications and features, live product demonstrations, site visits, and negotiations with vendors led to a progressive narrowing of the field of eligible EMR systems. Final scoring was based on three main themes of clinical usability, data quality and vendor maturity issues. RESULTS: The field of eligible EMR systems was relatively easily narrowed to a few finalists. Determination of the important strengths and weaknesses of these systems' usability, data extraction capabilities and vendor viability, required the full suite of evaluation steps. Preferences varied amongst clinicians and between clinicians and technical specialists, particularly regarding the importance of user interface versus database issues. However, the final scoring process showed consensus amongst clinical and technical experts. CONCLUSION: A rigorous, multidisciplinary process is useful in EMR selection. While prolonged and laborious, it is transparent, enhances buy in and realism of expectations by multiple potential users and IT support staff and may, therefore, improve the ultimate success of any EMR implementation project.     

User perception and experience of the introduction of a novel critical care patient viewer in the ICU setting

ObjectiveFailure to rapidly identify high-value information due to inappropriate output may alter user acceptance and satisfaction. The information needs for different intensive care unit (ICU) providers are not the same. This can obstruct successful implementation of electronic medical record (EMR) systems. We evaluated the implementation experience and satisfaction of providers using a novel EMR interface—based on the information needs of ICU providers—in the context of an existing EMR system.MethodsThis before–after study was performed in the ICU setting at two tertiary care hospitals from October 2013 through November 2014. Surveys were delivered to ICU providers before and after implementation of the novel EMR interface. Overall satisfaction and acceptance was reported for both interfaces.ResultsA total of 246 before (existing EMR) and 115 after (existing EMR + novel EMR interface) surveys were analyzed. 14% of respondents were prescribers and 86% were non-prescribers. Non-prescribers were more satisfied with the existing EMR, whereas prescribers were more satisfied with the novel EMR interface. Both groups reported easier data gathering, routine tasks & rounding, and fostering of team work with the novel EMR interface. This interface was the primary tool for 18% of respondents after implementation and 73% of respondents intended to use it further. Non-prescribers reported an intention to use this novel interface as their primary tool for information gathering.ConclusionCompliance and acceptance of new system is not related to previous duration of work in ICU, but ameliorates with the length of EMR interface usage. Task-specific and role-specific considerations are necessary for design and successful implementation of a EMR interface. The difference in user workflows causes disparity of the way of EMR data usage.     

Privacy-preserving screen capture: Towards closing the loop for health IT usability

As information technology permeates healthcare (particularly provider-facing systems), maximizing system effectiveness requires the ability to document and analyze tricky or troublesome usage scenarios. However, real-world health IT systems are typically replete with privacy-sensitive data regarding patients, diagnoses, clinicians, and EMR user interface details; instrumentation for screen capture (capturing and recording the scenario depicted on the screen) needs to respect these privacy constraints. Furthermore, real-world health IT systems are typically composed of modules from many sources, mission-critical and often closed-source; any instrumentation for screen capture can rely neither on access to structured output nor access to software internals.In this paper, we present a tool to help solve this problem: a system that combines keyboard video mouse (KVM) capture with automatic text redaction (and interactively selectable unredaction) to produce precise technical content that can enrich stakeholder communications and improve end-user influence on system evolution. KVM-based capture makes our system both application-independent and OS-independent because it eliminates software-interface dependencies on capture targets. Using a corpus of EMR screenshots, we present empirical measurements of redaction effectiveness and processing latency to demonstrate system performances. We discuss how these techniques can translate into instrumentation systems that improve real-world health IT deployments.